17.5095.03000 NORTH DAKOTA LEGISLATIVE MANAGEMENT Minutes of the HEALTH SERVICES COMMITTEE Wednesday, April 13, 2016 Roughrider Room, State Capitol Bismarck, North Dakota Senator Judy Lee, Chairman, called the meeting to order at 9:00 a.m. Members present: Senators Judy Lee, Howard C. Anderson, Jr., Tyler Axness, Joan Heckaman, Dave Oehlke, John M. Warner; Representatives Alan Fehr, Gail Mooney, Gary Paur, Todd Porter, Karen M. Rohr, Jay Seibel Members absent: Representatives Rich S. Becker, Dwight Kiefert, Marie Strinden Others present: Senator Rich Wardner, Dickinson, member of the Legislative Management See Appendix A for additional persons present. It was moved by Representative Seibel, seconded by Representative Rohr, and carried on a voice vote that the minutes of the January 7, 2016, meeting be approved as distributed. DENTAL SERVICES STUDY Chairman Lee welcomed Dr. Louis W. Sullivan, Former Secretary, United States Department of Health and Human Services. Dr. Sullivan provided information (Appendix B) regarding access to oral health care and dental health workforce issues. He said oral health is an integral part of overall health and poor oral health increases risk for diabetes, heart disease, and poor birth outcomes. He said over the past 20 years, the number of dental health professional shortage areas in the country has grown from nearly 800 in 1993 to more than 4,900 in 2014. He said dental caries disproportionately impact low-income and rural populations. He said North Dakota has one of the highest Medicaid reimbursement rates nationwide (62 percent in 2013), but only 8 percent of the dental practices billing Medicaid in 2013 provided care to a majority (52 percent) of the Medicaid enrollees accessing dental services. He said the dentist-to-population ratio is approximately 54 per 100,000 in North Dakota, and as of 2013, 67 percent of all the licensed North Dakota dentists worked in the four largest counties--Burleigh, Cass, Grand Forks, and Ward. He said 12 counties had no dentist, 9 counties had 1 dentist, and 9 counties had 2 dentists. He said if oral health needs are to be met, new models of care must be considered and one proven model is the dental therapist model. He said similar to nurse practitioners and physician assistants in medicine, dental therapists are professionally trained, mid-level dental providers who can improve access to dental care. He said dental therapists support the work of a dentist and can work in different locations, using telehealth technology, while under a dentist's supervision. He said by adopting and implementing standards for dental therapy education, the Commission on Dental Accreditation (CODA) has ensured that the quality and scope of educational training for dental therapists will be consistent from one state to another. He said mid-level dental providers have been in place in other countries for up to 90 years and in New Zealand, a school-based delivery system using dental therapists has been in place since 1921. He said dental therapists should be seen as an asset to a dental practice, bringing increased revenue and freeing up dentists to focus on more complex procedures. He said the dental system, as it is, is not working and must be improved. He said the mid-level dental providers will improve the dental team. In response to a question from Senator Anderson, Dr. Sullivan said he anticipates mid-level dental providers will eventually be accepted just as physician's assistants and nurse practitioners were eventually accepted in the medical field. Dr. Sullivan said when dentists see the opportunity to increase access to care and revenue, they will be convinced. In response to a question from Representative Paur, Dr. Sullivan said he is not aware of an increase in adverse incidents for individuals treated by mid-level dental providers. Dr. Sullivan said the scope of practice of a mid-level provider is limited and programs are monitored. In response to a question from Representative Rohr, Dr. Sullivan said prescriptions are provided under the supervision of the dentist. North Dakota Legislative Council April 13, 2016 17.5095.03000 Health Services Committee Dr. Sherin Tooks, Director, Commission on Dental Accreditation, provided information (Appendix C) regarding CODA resources, dental therapy program accreditation standards, the process used to approve and implement the standards, and the dental therapy timeline and implementation. She said CODA is recognized as the national programmatic accrediting agency for dental and dental-related educational programs and accredits programs, but not individuals or institutions in which the programs reside. She said CODA has not taken a position on the merits of dental therapy and the scope of practice of the dental therapist is within the purview of each state. She said accreditation standards may be used by regulatory agencies to define scopes of practice. She said draft dental therapy standards were written in 2013 and circulated for comment for 1 year. She said the standards were revised in 2014 and circulated an additional year. She said after the standards were adopted, an implementation process was developed in 2015. She said in February 2016 CODA adopted the process of accreditation for dental therapy education programs and began accepting applications for accreditation of dental therapy programs. She said the CODA application process includes application review and an on-site accreditation evaluation visit. She said dental therapy accreditation standards consider institutional effectiveness; educational program; faculty and staff; educational support services; and health, safety, and patient care provisions. She said dental therapy accreditation standards provide for advanced standing and allow for career laddering. In response to a question from Senator Warner, Dr. Tooks said the first draft of the dental therapy accreditation standards included a baccalaureate degree; however, CODA determined the degree should be determined by the institution. Dr. Tooks said CODA requires a 3 academic year (August through May) or equivalent, full-time, postsecondary program. She said the institution determines what degree will be awarded upon completion. In response to a question from Senator Warner, Dr. Tooks said the opportunity exists for career laddering from a dental therapy degree to dental school. Dr. Tooks said the degree to which dental hygienists and dental therapists are able to receive advanced standing in dental school will depend on their level of training and the advance standing policies and procedures of the dental program. She said the dental school would need to adopt appropriate mechanisms to ensure dental therapy candidates entering dental school with advanced standing satisfy the same level of competency as students receiving the full dental school experience. In response to a question from Chairman Lee, Dr. Tooks said peer review is outside of the scope of CODA. Dr. Tooks said CODA is limited to assessing educational programs. She said licensing and practice oversight is the responsibility of states and their professional licensing boards. In response to a question from Representative Rohr, Dr. Tooks said the consequence of noncompliance depends on the deficiency. Dr. Tooks said if the deficiency is severe, CODA may withhold accreditation; however, a deficiency that is less severe could allow for accreditation, with followup monitoring and review. She said programs are allowed to become compliant with close monitoring and reporting requirements. She said CODA accreditation is not a requirement for student financial aid. In response to a question from Chairman Lee, Dr. Tooks said to maintain accreditation, programs must submit an annual report for review, including information regarding admission rates, graduation rates, program changes, and curriculum data collection. Dr. Tooks said CODA also has a program change policy which requires CODA be notified of certain program changes. Ms. Kimberlie Yineman, Oral Health Program Director, State Department of Health, and Vice President, North Dakota Oral Health Coalition, provided information (Appendix D) regarding the efforts of the North Dakota Collaborative Practice Task Force. She said the task force reviewed, discussed, and agreed upon key elements of a collaborative practice by reviewing current state supervision laws. She said task force members solicited input from individuals who had prior experience with collaborative practice from an implementation and policy perspective. She said the task force agreed collaborative practice agreements should maintain and improve current quality standards of care and safety, increase access to care with the best interests of the patient in mind, and link patients to a dental home. She said in December 2015 the North Dakota Collaborative Practice Task Force concluded existing North Dakota Century Code (NDCC) Sections 43-20-03, 43-20-01, 43-28-18, and North Dakota Administrative Code (NDAC) Section 20-04-01-01, as they related to collaborative practice and supervision, should remain. She said the task force agreed that existing language in NDAC describes a collaborative practice model that works best for the state. She said NDAC Chapter 20-01-02 defines general supervision to mean the dentist has authorized the procedures and they are carried out in accordance with the dentist's diagnosis, if necessary, and treatment plan. She said the dentist is not required to be in the treatment facility and limitations are contained in NDCC Section